Iggy Questions Exam 3 10th edition

Question 1

A nurse in the oncology clinic is providing preop education to a client just diagnosed with cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is best?
a. Call the client at home the next day to review teaching.
b. Give the client information about a cancer support group.
c. Provide all the preoperative instructions in writing.
d. Reassure the client that surgery will be over soon.

Answer 1

a. Call the client at home the next day to review teaching

Question 2

A nurse is caring for a client admitted for Non-Hodgkin’s lymphoma and chemotherapy. The client reports nausea, flank pain, and muscle cramps. What action by the nurse is most important?
a. Request an order for serum electrolytes and uric acid.
b. Increase the client’s IV infusion rate.
c. Instruct assistive personnel to strain all urine.
d. Administer an IV antiemetic.

Answer 2

A. request and order for serum electrolytes and uric acid

This client’s reports are consistent with tumor lysis syndrome, for which he or she is at risk due to the diagnosis. Early symptoms of TLS stem from electrolyte imbalances and can include lethargy, nausea, vomiting, anorexia, flank pain, muscle weakness, cramps, seizures, and altered mental status. The nurse would notify the primary health care provider and request an order for serum electrolytes. Hydration is important in both preventing and managing this syndrome, but the nurse would not just increase the IV rate. Assistive personnel may need to strain the client’s urine and the client may need an antiemetic, but first the nurse would assess the situation further by obtaining pertinent lab tests.

Question 3

The nurse working with oncology clients understands that which age-related change increases the older client’s susceptibility to infection during chemotherapy?
a. Decreased immune function
b. Diminished nutritional stores
c. Existing cognitive deficits
d. Poor physical reserves

Answer 3

A. decreased immune function

As people age, there is an age-related decrease in immune function, causing the older adult to be more susceptible to infection than other clients. Not all older adults have diminished nutritional stores, cognitive dysfunction, or poor physical reserves.

Question 4

The nurse has educated a client on precautions to take with thrombocytopenia. What statement by the client indicates a need to review the information?
a. “I will be careful if I need enemas for constipation.”
b. “I will use an electric shaver instead of a razor.”
c. “I should only eat soft food that is either cool or warm.”
d. “I won’t be able to play sports with my grandkids.”

Answer 4

A. I will be careful if I need enemas for constipation

The thrombocytopenic client is at high risk for bleeding even from minor trauma. Due to the risk of injuring rectal and anal tissue, the client should not use enemas or rectal thermometers. This statement would indicate the client needs more information. The other statements are appropriate for the thrombocytopenic client.

Question 5

A client has a platelet count of 9800/mm3 (9800 x 10^9/L). What action by the nurse is most appropriate?
a. Assess the client for calf pain, warmth, and redness.
b. Instruct the client to call for help to get out of bed.
c. Obtain cultures as per the facility’s standing policy.
d. Place the client on protective Isolation Precautions.

Answer 5

B. instruct the client to call for help to get out of bed

A client with a platelet count this low is at high risk for serious bleeding episodes. To prevent injury, the client would be instructed to call for help prior to getting out of bed. Calf pain, warmth, and redness might indicate a deep vein thrombosis, not associated with low platelets. Cultures and isolation relate to low white cell count

Question 6

A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL (61 mmol/L). The client is symptomatic but refuses blood transfusions. What medication does the nurse prepare to administer?
a. Epoetin alfa
b. Filgrastim
c. Mesna
d. Dexrazoxane

Answer 6

A. epoetin alfa

The client’s hemoglobin is very low, so the nurse prepares to administer epoetin alfa, a colony-stimulating factor that increases production of red blood cells. Filgrastim is for neutropenia. Mesna is used to decrease bladder toxicity from some chemotherapeutic agents. Dexrazoxane helps protect the heart from cardiotoxicity from other agents.

Question 7

A client with long-standing heart failure being treated for cancer has received a dose of ondansetron for nausea. What action by the nurse is most important?
a. Assess the client for a headache or dizziness.
b. Request a prescription for cardiac monitoring
c. Instruct the client to change positions slowly.
d. Weigh the client daily before eating.

Answer 7

B. Request a prescription for cardiac monitoring

5-HT3 antagonists, such as ondansetron, can prolong the QT interval within the cardiac conduction cycle. ECG monitoring is recommended in patients with electrolyte abnormalities (e.g., hypokalemia or hypomagnesemia), heart failure, bradyarrhythmias or patients taking other medications that can cause QT prolongation. The nurse would contact the primary health care provider and request cardiac monitoring. The nurse would assess the client for any other reported changes, but this is not a critical safety factor. Weight is not related directly to this drug.

Question 8

A client with cancer has anorexia and mucositis, and is losing weight. The client’s family members continually bring favorite foods to the client and are distressed when the client won’t eat them. What action by the nurse is best?
a. Explain the pathophysiologic reasons behind the client not eating.
b. Help the family show other ways to demonstrate love and caring.
c. Suggest foods and liquids the client might be willing to try to eat.
d. Tell the family the client isn’t able to eat now no matter what they bring.

Answer 8

B. Help the family show other ways to demonstrate love and caring

Families often become distressed when their loved ones won’t eat. Providing food is a universal sign of caring, and to some people the refusal to eat signifies worsening of the condition. The best option for the nurse is to help the family find other ways to demonstrate caring and love, because with treatment-related anorexia and mucositis, the client is not likely to eat anything right now. Explaining the rationale for the problem is a good idea but does not suggest to the family anything that they can do for the client. Simply telling the family the client is not able to eat does not give them useful information and is dismissive of their concerns.

Question 9

The nurse caring for clients who have cancer understands that the general consequences of cancer include which client problems? (Select all that apply.)
a. Clotting abnormalities from thrombocythemia
b. Increased risk of infection from white blood cell deficits
c. Nutritional deficits such as early satiety and cachexia
d. Potential for reduced gas exchange
e. Various motor and sensory deficits
f. Increased risk of bone fractures

Answer 9

A, B, C, D, E, F

The general consequences of cancer include reduced immunity and blood-producing functions, altered GI structure and function, decreased respiratory function, and motor and sensory deficits. Clotting problems often occur due to thrombocytopenia (not enough platelets), not thrombocythemia (too many platelets).

Question 10

A client has thrombocytopenia. What actions does the nurse delegate to assistive personnel (AP)? (Select all that apply.)
a. Apply the client’s shoes before getting the client out of bed.
b. Assist the client with ambulation.
c. Shave the client with a safety razor only.
d. Use a lift sheet to move the client up in bed.
e. Use a water pressure device be set on low for oral care.

Answer 10

A, B, D

Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries. The nurse instructs the AP to put the client’s shoes on before getting the client out of bed, assist with ambulation, shave the client with an electric razor, use a lift sheet when needed to reposition the client, and use a soft-bristled toothbrush for oral care. All of these measures help prevent client injury.

Question 11

7. A client receiving chemotherapy has a white blood cell count of 1000/mm3 (1  109/L). What actions by the nurse are most appropriate? (Select all that apply.)
   a. Assess all mucous membranes every 4 to 8 hours.
   b. Do not allow the client to eat meat or poultry.
   c. Listen to lung sounds and monitor for cough.
   d. Monitor the venous access device appearance hourly.
   e. Take and record vital signs every 4 to 8 hours.
   f. Encourage activity the client can tolerate.

Answer 11

A, C, D, E

Depending on facility protocol, the nurse would assess this client for infection every 4 to 8 hours by assessing all mucous membranes, listening to lung sounds, monitoring for cough, monitoring the appearance of the venous access device, and recording vital signs. Assisting the client with mobilization will also help prevent infection. Eating meat and poultry is allowed.

Question 12

The nurse is assessing an older client for any potential hematologic health problem. Which assessment finding is the most significant and would be reported to the primary health care provider?
a. Poor skin turgor on both forearms
b. Multiple petechiae and large bruises
c. Dry, flaky skin on arms and legs
d. Decreased body hair distribution

Answer 12

B. multiple petechiae and large bruises

The presence of multiple petechiae and large bruises indicate a possible problem with blood clotting. Older adults typically have poor skin turgor and dry, flaky skin due to decreased body fluid as a result of aging. They also lose body hair or have thinning hair as a normal change of aging.

Question 13

A hospitalized client has a platelet count of 58,000/mm3 (58 x 10^9/L). What action by the nurse is most appropriate?
a. Encourage high-protein foods.
b. Institute neutropenic precautions.
c. Limit visitors to healthy adults.
d. Place the client on safety precautions.

Answer 13

D. place the client on safety precautions

With a platelet count between 40,000 and 80,000/mm3 (40 and 80 x 10^9/L), clients are at risk of prolonged bleeding even after minor trauma. The nurse would place the client on safety or bleeding precautions as the most appropriate action. High-protein foods, while healthy, are not the priority. Neutropenic precautions are not needed as the patient’s white blood cell count is not low. Limiting visitors would also be more likely related to a low white blood cell count.

Question 14

While taking a client history, which factor(s) that place the client at risk for a hematologic health problem will the nurse document? (Select all that apply.)
a. Family history of bleeding problems
b. Diet low in iron and protein
c. Excessive alcohol consumption
d. Family history of allergies
e. Diet high in saturated fats
f. Diet high in Vitamin K

Answer 14

A, C, F

A family history of bleeding problems places the client at risk for having a similar problem. Excessive alcohol can damage the liver where prothrombin is produced. A diet high in Vitamin K can cause excessive clotting because it is a major clotting factor.

Question 15

An older client asks the nurse why “people my age” have weaker immune systems than younger people. What responses by the nurse are best? (Select all that apply.)
a. “Bone marrow produces fewer blood cells as you age.”
b. “You may have decreased levels of circulating platelets.”
c. “You have lower levels of plasma proteins in the blood.”
d. “Lymphocytes become more reactive to antigens.”
e. “Spleen function declines after age 60.”

Answer 15

A, C

Question 16

The nurse is assessing a client experiencing anemia. Which laboratory findings will the nurse expect for this client? (Select all that apply.)
a. Increased hematocrit
b. Decreased red blood cell count
c. Decreased serum iron
d. Decreased hemoglobin
e. Increased platelet count
f. Decreased white blood cell count

Answer 16

B, C, D

Clients experiencing anemia have a decreased red blood cell count which leads to a decreased hemoglobin and hematocrit. For some clients, serum iron levels are also decreased. Anemia is not a problem involving platelets or white blood cells.

Question 17

A nurse works in a gerontology clinic. What age-related change(s) related to the hematologic system will the nurse expect during health assessment? (Select all that apply.)
a. Dentition deteriorates with more cavities.
b. Nail beds may be thickened or discolored.
c. Progressive loss or thinning of hair occurs.
d. Sclerae begin to turn yellow or pale.
e. Skin becomes more oily.

Answer 17

B, C

Common findings in older adults include thickened or discolored nail beds, dry (not oily) skin, and thinning hair. The nurse adapts to these changes by altering assessment techniques. Having more dental caries and changes in the sclerae are not normal age-related changes.

Question 18

The nurse is teaching a client who has pernicious anemia about necessary dietary changes. Which statement by the client indicates understanding about those changes?
a. “I’ll increase animal proteins like fish and meat.”
b. “I’ll work on increasing my fats and carbohydrates.”
c. “I’ll avoid eating green leafy vegetables.
d. “I’ll limit my intake of citrus fruits”

Answer 18

A. “I’ll increase animal proteins like fish and meat.”

Clients who have pernicious anemia have a Vitamin B12 deficiency and need to consume foods high in Vitamin B12, such as animal and plant proteins, citrus fruits, green leafy vegetables, and dairy products. While carbohydrates and fats can provide sources of energy, they do not supply the necessary nutrient to improve anemia.

Question 19

An assistive personnel is caring for a client with leukemia and asks why the client is still at risk for infection when the white blood cell count (WBC) is high. What response by the nurse is correct?
a. “If the WBCs are high, there already is an infection present.”
b. “The client is in a blast crisis and has too many WBCs.”
c. “There must be a mistake; the WBCs should be very low.”
d. “Those WBCs are abnormal and don’t provide protection.”

Answer 19

D. “Those WBCs are abnormal and don’t provide protection”

In leukemia, the WBCs are abnormal and do not provide protection to the client against infection. The other statements are not accurate.

Question 20

The family of a neutropenic client reports that the client “is not acting right.” What action by the nurse is the priority?
a. Ask the client about pain.
b. Assess the client for infection.
c. Take a set of vital signs.
d. Review today’s laboratory results.

Answer 20

B. assess the client for infection

Neutropenic clients often do not have classic manifestations of infection, but infection is the most common cause of death in neutropenic clients. The nurse would definitely assess for infection. The nurse would assess for pain but this is not the priority.

Question 21

A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope with the long recovery period, what action by the nurse is best?
a. Arrange a visitation schedule among friends and family.
b. Explain that this process is difficult but must be endured.
c. Help the client find things to hope for each day of recovery.
d. Provide plenty of diversionary activities for this time

Answer 21

C. help the client find things to hope for each day of recovery

Providing hope is an essential nursing function during treatment for any disease process, but especially during the recovery period after bone marrow transplantation, which can take up to 3 weeks. The nurse can help the client look ahead to the recovery period and identify things to hope for during this time. Visitors are important to clients, but may pose an infection risk. Telling the client that the recovery period must be endured does not acknowledge his or her feelings. Diversionary activities are important, but not as important as instilling hope.

Question 22

A client asks about the process of graft-versus-host disease. What explanation by the nurse is correct?
a. “Because of immunosuppression, the donor cells take over.”
b. “It’s like a transfusion reaction because no perfect matches exist.”
c. “The patient’s cells are fighting donor cells for dominance.”
d. “The donor’s cells are actually attacking the patient’s cells.”

Answer 22

D. “The donor’s cells are actually attacking the patient’s cells.”

Graft-versus-host disease is an autoimmune-type process in which the donor cells recognize the client’s cells as foreign and begin attacking them. The other answers are not accurate.

Question 23

The nurse is caring for a patient with leukemia who has severe fatigue. What action by the client best indicates that an important outcome to manage this problem has been met?
a. Doing activities of daily living (ADLs) using rest periods
b. Helping plan a daily activity schedule
c. Requesting a sleeping pill at night
d. Telling visitors to leave when fatigued

Answer 23

A. Doing ADLs using rest periods

Fatigue is a common problem for clients with leukemia. This client is managing his or her own ADLs using rest periods, which indicates an understanding of fatigue and how to control it. Helping to plan an activity schedule is a lesser indicator. Requesting a sleeping pill does not help control fatigue during the day. Asking visitors to leave when tired is another lesser indicator. Managing ADLs using rest periods demonstrates the most comprehensive management strategy.

Question 24

A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a priority?
a. Genetic testing
b. Infection prevention
c. Sperm banking
d. Treatment options

Answer 24

C. sperm banking

All teaching topics are important to the client with lymphoma, but for a young male, sperm banking is of particular concern if the client is going to have radiation to the lower abdomen or pelvis.

Question 25

A client has been admitted after sustaining a humerus fracture that occurred when picking up the family cat. What test result would the nurse correlate to this condition?
a. Bence-Jones protein in urine
b. Epstein-Barr virus: positive
c. Hemoglobin: 18 mg/dL (180 mmol/L)
d. Red blood cell count: 8.2 million/mcL (8.2  1012/L)

Answer 25

A. Bence-Jones protein in urine

This client has possible multiple myeloma. A positive Bence-Jones protein finding would correlate with this condition. The Epstein-Barr virus is a herpesvirus that causes infectious mononucleosis and some cancers. A hemoglobin of 18 mg/dL (180 mmol/L) is slightly high for a male and somewhat high for a female; this can be caused by several conditions, and further information would be needed to correlate this value with a specific medical condition. A red blood cell count of 8.2 million/mcL (8.2  1012/L) is also high, but again, more information would be needed to correlate this finding with a specific medical condition.

Question 26

A client with multiple myeloma demonstrates worsening bone density on diagnostic scans. About what drug does the nurse plan to teach this client?
a. Bortezomib
b. Dexamethasone
c. Thalidomide
d. Zoledronic acid

Answer 26

D. zoledronic acid

All the options are drugs used to treat multiple myeloma, but the drug used specifically for bone manifestations is zoledronic acid, which is a bisphosphonate. This drug class inhibits bone resorption and is used to treat osteoporosis as well.

Question 27

A client has a platelet count of 9000/mm3 (9 x 10^9/L). The nurse finds the client confused and mumbling. What nursing action takes priority at this time?
a. Call the Rapid Response Team.
b. Take a set of vital signs.
c. Institute bleeding precautions.
d. Place the client on bedrest.

Answer 27

A. Call the Rapid Response Team

With a platelet count this low, the client is at high risk of spontaneous bleeding. The most disastrous complication would be intracranial bleeding. The nurse needs to call the Rapid Response Team as this client has manifestations of a sudden neurologic change. Bleeding precautions will not address the immediate situation. Placing the client on bedrest is important, but the critical action is to call for immediate medical attention.

Question 28

A nurse is preparing to administer a blood transfusion. What action is most important?
a. Correctly identify client using two identifiers.
b. Ensure that informed consent is obtained.
c. Hang the blood product with Ringer’s lactate.
d. Stay with the client for the entire transfusion.

Answer 28

B. ensure that informed consent is obtained

Question 29

A nurse is preparing to administer a blood transfusion. Which action is most important?
a. Document the transfusion.
b. Place the client on NPO status.
c. Place the client in isolation.
d. Put on a pair of gloves.

Answer 29

D. put on a pair of gloves

Question 30

A client has thrombocytopenia. What statement indicates that the client understands self-management of this condition?
a. “I brush and use dental floss every day.”
b. “I chew hard candy for my dry mouth.”
c. “I usually put ice on bumps or bruises.”
d. “Nonslip socks are best when I walk.”

Answer 30

C. I usually put ice on bumps or bruises

The client should be taught to apply ice to areas of minor trauma. Flossing is not recommended. Hard foods should be avoided. The client should wear well-fitting shoes when ambulating.

Question 31

A nurse is caring for four clients with leukemia. After hand-off report, which client would the nurse assess first?
a. Client who had two bloody diarrhea stools this morning.
b. Client who has been premedicated for nausea prior to chemotherapy.
c. Client with a respiratory rate change from 18 to 22 breaths/min.
d. Client with an unchanged lesion to the lower right lateral malleolus.

Answer 31

A. client who had two bloody diarrhea stools this morning

The client who had two bloody diarrhea stools that morning may be hemorrhaging in the gastrointestinal (GI) tract and should be assessed first to monitor for or avoid the client from going into hypovolemic shock. The client with the slight change in respiratory rate may have an infection or worsening anemia and should be seen next. If the client’s respiratory rate was greater than 28 to 30 breaths/min, the client may need the initial assessment. Marked tachypnea is an early sign of a deteriorating client condition. The other two clients are not a priority at this time.

Question 32

Which statement by a client with leukemia indicates a need for further teaching by the nurse?
a. “I will use a soft-bristled toothbrush and avoid flossing.”
b. “I will not take aspirin or any aspirin product.”
c. “I will use an electric shaver instead of my manual one.”
d. “I will take a daily laxative to prevent constipation”

Answer 32

D. “I will take a daily laxative to prevent constipation”

The client experiencing leukemia needs to prevent injury to prevent bleeding, including avoiding hard-bristled toothbrushes, floss, aspirin, and straight or manual safety razors. However, although constipation can cause hemorrhoids or rectal bleeding, laxatives can cause fluid and electrolyte imbalances and abdominal cramping. Stool softeners would be a better option to allow the passage of soft stool.

Question 33

The nurse is assessing a client who has probable lymphoma. What is the most common early assessment finding for clients with this disorder?
a. Weight gain
b. Enlarged painless lymph node(s)
c. Fever at night
d. Nausea and vomiting

Answer 33

B. enlarged painless lymph node(s)

The first change that is noted for clients with probable lymphoma is one or more enlarged lymph nodes. The other findings are either not common in clients with lymphoma or later findings.

Question 34

Which risk factor(s) places a client at risk for leukemia? (Select all that apply.)
a. Chemical exposure
b. Genetically modified foods
c. Ionizing radiation exposure
d. Vaccinations
e. Viral infections

Answer 34

A, C, E

Chemical and ionizing radiation exposure and viral infections are known risk factors for developing leukemia. Eating genetically modified food and receiving vaccinations are not known risk factors.

Question 35

The nurse is assessing a client with chronic leukemia. Which laboratory test result(s) is (are) expected for this client? (Select all that apply.)
a. Decreased hematocrit
b. Abnormal white blood cell count
c. Low platelet count
d. Decreased hemoglobin
e. Increased albumin

Answer 35

A, B, C, D

Chronic leukemia affects all types of blood cells causing a decrease is red blood cells (RBCs) and platelets. When the number of RBCs decreases, the client’s hemoglobin and hematocrit also decrease. White blood cell counts are also abnormal depending on disease progression and management.

Question 36

The nurse is caring for a client being treated for Hodgkin lymphoma. For which side effect(s) of treatment will the nurse assess? (Select all that apply.)
a. Severe nausea and vomiting
b. Low platelet count
c. Skin irritation at radiation site
d. Low red blood cell count
e. High white blood cell count

Answer 36

A, B, C, D

Drug and radiation therapy for Hodgkin lymphoma cause many side and adverse effects, including all of the choices except for a high white blood cell (WBC) count. Instead, most clients experience a low WBC count making them very susceptible to infections.

Question 37

A client has received a bone marrow transplant and is waiting for engraftment. What action(s) by the nurse are most appropriate? (Select all that apply.)
a. Not allowing any visitors until engraftment
b. Limiting the protein in the client’s diet
c. Placing the client in protective precautions
d. Teaching visitors appropriate hand hygiene
e. Telling visitors not to bring live flowers or plants

Answer 37

C, D, E

The client waiting for engraftment after bone marrow transplant has no white cells to protect him or her against infection. The client is on protective precautions and visitors are taught hand hygiene. No fresh flowers or plants are allowed due to the standing water in the vase or container that may harbor organisms; clients are also told not to work with houseplants in the home. Limiting protein is not a healthy option and will not promote engraftment.

Question 38

The nurse is assessing a client with a diagnosis of prerenal acute kidney injury (AKI). Which condition would the nurse expect to find in the patient’s recent history?
a. Pyelonephritis
b. Dehydration
c. Bladder cancer
d. Kidney stones

Answer 38

B. dehydration

Prerenal causes of AKI are related to a decrease in perfusion, such as in clients who have prolonged dehydration. Pyelonephritis is an intrinsic or intrarenal cause of AKI related to kidney damage. Bladder cancer and kidney stones are postrenal causes of AKI related to urine flow obstruction.

Question 39

A marathon runner comes into the clinic and states “I have not urinated very much in the last few days.” The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is most appropriate?
a. Give the client a bottle of water immediately.
b. Start an intravenous line for fluids.
c. Teach the patient to drink 2 to 3 L of water daily.
d. Perform an electrocardiogram.

Answer 39

A. Give the client a bottle of water immediately

This athlete is mildly dehydrated as evidenced by the higher heart rate and lower blood pressure. The nurse can start hydrating the client with a bottle of water first, followed by teaching the patient to drink 2 to 3 L of water each day. An intravenous line may be needed later, after the patient’s degree of dehydration is assessed. An electrocardiogram is not necessary at this time.

Question 40

A client comes into the emergency department with a serum creatinine of 2.2 mg/dL (1944 mcmol/L) and a blood urea nitrogen (BUN) of 24 mL/dL (8.57 mmol/L). What question would the nurse ask first when taking this client’s history?
a. “Have you been taking any aspirin, ibuprofen, or naproxen recently?”
b. “Do you have anyone in your family with renal failure?”
c. “Have you had a diet that is low in protein recently?”
d. “Has a relative had a kidney transplant lately?”

Answer 40

a. “Have you been taking any aspirin, ibuprofen, or naproxen recently?”

There are some medications that are nephrotoxic, such as the nonsteroidal anti-inflammatory drugs ibuprofen, aspirin, and naproxen. This would be a good question to initially ask the patient since both the serum creatinine and BUN are elevated, indicating some renal problems. A diet high in protein could be a factor in an increased BUN.

Question 41

A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this patient’s care?
a. Edema and pain
b. Cardiac and respiratory status
c. Electrolyte and fluid imbalance
d. Mental health status

Answer 41

c. Electrolyte and fluid imbalance

This client may have an inflammatory cause of AKI with proteins entering the glomerulus and holding the fluid in the filtrate, causing polyuria. Electrolyte loss and fluid balance are essential. Edema and pain are not usually a problem with fluid loss. There could be changes in the client’s cardiac, respiratory, and mental health status if the electrolyte imbalance is not treated.

Question 42

A client with acute kidney injury (AKI) has a blood pressure of 76/55 mm Hg. The primary health care provider prescribed 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client starts to develop shortness of breath. What is the nurse’s priority action?
a. Calculate the mean arterial pressure (MAP).
b. Ask for insertion of a pulmonary artery catheter.
c. Take the client’s pulse.
d. Decrease the rate of the IV infusion.

Answer 42

D. Decrease the rate of the IV infusion.

The nurse would assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline infusion. The calculation of the MAP also reflects perfusion. The insertion of a pulmonary artery catheter would evaluate the client’s hemodynamic status, but this would not be the initial or priority action by the nurse. Vital signs are also important after adjusting the intravenous infusion.

Question 43

A client has a serum potassium level of 6.5 mEq/L (6.5 mmol/L), a serum creatinine level of 2 mg/dL (176 mcmol/L), and a urine output of 350 mL/day. What is the best action by the nurse?
a. Place the client on a cardiac monitor immediately.
b. Teach the client to limit high-potassium foods.
c. Continue to monitor the client’s intake and output.
d. Ask to have the laboratory redraw the blood specimen.

Answer 43

A. Place the client on a cardiac monitor immediately

The best action by the nurse would be to check the cardiac status with a monitor. High-potassium levels can lead to dysrhythmias. The other choices are logical nursing interventions for acute kidney injury but not the best immediate action.

Question 44

A client with diabetes mellitus type 2 has been well controlled with metformin. The client is scheduled for magnetic resonance imaging (MRI) scan with contrast. What priority would the nurse take at this time?
a. Teach the client about the purpose of the MRI.
b. Assess the client’s blood urea nitrogen and creatinine.
c. Tell the client to withhold metformin for 24 hours before the MRI.
d. Ask the client if he or she is taking antibiotics.

Answer 44

c. Tell the client to withhold metformin for 24 hours before the MRI.

Contrast media can be nephrotoxic (damaging to the kidneys). Metformin can also be nephrotoxic and the client should not be exposed to two agents. Clients who have diabetes are already at risk for renal damage.

Question 45

The nurse is caring for four clients with chronic kidney disease (CKD). Which client would the nurse assess first upon initial rounding?
a. Client with a blood pressure of 158/90 mm Hg
b. Client with Kussmaul respirations
c. Client with skin itching from head to toe
d. Client with halitosis and stomatitis

Answer 45

B. client with kussmaul respirations

Kussmaul respirations indicate that the client has metabolic acidosis which is a complication of CKD. The client is increasing the rate and depth of breathing to excrete carbon dioxide through the lungs to lower serum pH. Hypertension is common in most patients with CKD, and skin itching increases with calcium–phosphate imbalances and elevations of nitrogenous wastes, another common finding in CKD. Uremia from CKD causes ammonia to be formed, resulting in the common findings of halitosis and stomatitis.

Question 46

The nurse is teaching assistive personnel (AP) about fluid restriction for a client who has acute kidney injury (AKI). The client’s 24-hour urinary output is 120 mL. How much fluid would the client be allowed to have over the next 24 hours?
a. 380 mL
b. 500 mL
c. 620 mL
d. 750 mL

Answer 46

c. 620 mL

The general principle for fluid restriction for clients is that they may have a daily fluid intake of 500 mL plus the amount of their urinary output. In this case, 120 mL urinary output plus 500 mL equals 620 mL fluid allowance

Question 47

A client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse?
a. Discuss what the treatment regimen means to the client.
b. Refer the client to a mental health nurse practitioner.
c. Reschedule the appointments to another date and time.
d. Discuss the option of peritoneal dialysis.

Answer 47

a. Discuss what the treatment regimen means to the client.

The initial action for the nurse is to assess anxiety, coping styles, and the client’s acceptance of the required treatment for CKD. The client may be in denial of the diagnosis. While rescheduling hemodialysis appointments may help, and referral to a mental health practitioner and the possibility of peritoneal dialysis are all viable options, assessment of the client’s acceptance of the treatment would come first.

Question 48

A client is taking furosemide 40 mg/day for management of early chronic kidney disease (CKD). To assess the therapeutic effect of the medication, what action of the nurse is best?
a. Obtain daily weights of the client.
b. Auscultate heart and breath sounds.
c. Palpate the client’s abdomen.
d. Assess the client’s diet history.

Answer 48

A. obtain DW of the client

Furosemide is a loop diuretic that helps reduce fluid overload and hypertension in patients with early stages of CKD. One kilogram of weight equals about 1 L of fluid retained in the client, so daily weights are necessary to monitor the response of the client to the medication. Heart and breath sounds would be assessed if there is fluid retention, as in heart failure. Palpation of the client’s abdomen is not necessary, but the nurse would check for edema. The diet history of the client would be helpful to assess electrolyte replacement since potassium is lost with this diuretic, but this does not assess the effectiveness of the medication.

Question 49

A 70-kg adult client with chronic kidney disease (CKD) is on a 40-g protein diet. The patient has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would be of most concern to the nurse?
a. Albumin level of 2.5 g/dL (3.63 mcmol/L)
b. Phosphorus level of 5 mg/dL (1.62 mmol/L)
c. Sodium level of 135 mEq/L (135 mmol/L)
d. Potassium level of 5.5 mEq/L (5.5 mmol/L)

Answer 49

A. Albumin level of 2.5 g/dL (3.63 mcmol/L)

Protein restriction is necessary with CKD due to the buildup of waste products from protein breakdown. The nurse would be concerned with the low albumin level since this indicates that the protein in the diet is not enough for the client’s metabolic needs. The electrolyte values are not related to the protein-restricted diet.

Question 50

The nurse is teaching a client with chronic kidney disease (CKD) about the sodium restriction needed in the diet to prevent edema and hypertension. Which statement by the client indicates that more teaching is needed?
a. “I will probably lose weight by cutting out potato chips.”
b. “I will cut out bacon with my eggs every morning.”
c. “My cooking style will change by not adding salt.”
d. “I am thrilled that I can continue to eat fast food.”

Answer 50

D. “I am thrilled that I can continue to eat fast food.”

Fast-food restaurants usually serve food that is high in sodium. This statement indicates that more teaching needs to occur. The other statements show a correct understanding of the teaching.

Question 51

A client is placed on fluid restriction because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the client’s fluid balance is stable at this time?
a. Decreased calcium levels
b. Increased phosphorus levels
c. No adventitious sounds in the lungs
d. Increased edema in the legs

Answer 51

c. No adventitious sounds in the lungs

The absence of adventitious sounds upon auscultation of the lungs indicates a lack of fluid overload and fluid balance in the client’s body. Decreased calcium levels and increased phosphorus levels are common findings with CKD. Edema would indicate a fluid imbalance.

Question 52

The charge nurse is orienting a new nurse about care for an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe?
a. Palpating the access site for a bruit or thrill
b. Using the right arm for a blood pressure reading
c. Administering intravenous fluids through the AV fistula
d. Checking distal pulses in the left arm

Answer 52

c. Administering intravenous fluids through the AV fistula

The nurse would not use the arm with the AV fistula for intravenous infusion, blood pressure readings, or venipuncture. Compression and infection can result in the loss of the AV fistula. The AV fistula would be monitored by auscultating or palpating the access site. Checking the distal pulse would be an appropriate assessment.

Question 53

A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse?
a. Warm the dialysate solution in a microwave before instillation.
b. Obtain a sample of the effluent and send to the laboratory.
c. Flush the tubing with normal saline to maintain patency of the catheter.
d. Check the peritoneal catheter for kinking and curling.

Answer 53

b. Obtain a sample of the effluent and send to the laboratory.

An opaque or cloudy effluent is the first sign of peritonitis. A sample of the effluent would need to be sent to the laboratory for culture and sensitivity in order to administer the correct antibiotic. Warming the dialysate in a microwave and flushing the tubing are not safe actions by the nurse. Checking the catheter for obstruction is a viable option but will not treat the peritonitis.

Question 54

The nurse is teaching a client how to increase the flow of dialysate into the peritoneal cavity during dialysis. Which statement by the client demonstrates a correct understanding of the teaching?
a. “I should leave the drainage bag above the level of my abdomen.”
b. “I could flush the tubing with normal saline if the flow stops.”
c. “I should take a stool softener every morning to avoid constipation.”
d. “My diet should have low fiber in it to prevent any irritation.”

Answer 54

c. “I should take a stool softener every morning to avoid constipation.”

Inflow and outflow problems of the dialysate are best controlled by preventing constipation. A daily stool softener is the best option for the client. The drainage bag should be below the level of the abdomen. Flushing the tubing will not help with the flow. A diet high in fiber will also help with a constipation problem.

Question 55

A nurse reviews the laboratory values of a client who returned from kidney transplantation 12 hours ago:
Sodium - 136
Potassium- 5
Blood urea nitrogen (BUN)- 44
Serum creatinine- 2.5
What initial intervention would the nurse anticipate?
a. Start hemodialysis immediately.
b. Discuss the need for peritoneal dialysis.
c. Increase the dose of immunosuppression.
d. Return the client to surgery for exploration.

Answer 55

c. Increase the dose of immunosuppression.

The client may need a higher dose of immunosuppressive medication as evidenced by the elevated BUN and serum creatinine levels. This increased dose may reverse the possible acute rejection of the transplanted kidney. The client does not need hemodialysis, peritoneal dialysis, or further surgery at this point.

Question 56

The nurse administers epoetin alfa to a client who has chronic kidney disease (CKD). Which laboratory test value would the nurse monitor to determine this drug’s effectiveness?
a. Potassium
b. Sodium
c. Renin
d. Hemoglobin

Answer 56

D. hemoglobin

The purpose of giving epoetin alfa to a client with CKD is to manage anemia by stimulating the bone marrow to produce more red blood cells. Therefore, monitoring the client’s hemoglobin, hematocrit, and red blood cell count would indicate if the drug was effective.

Question 57

A client with chronic kidney disease (CKD) has an elevated serum phosphorus level. What drug would the nurse anticipate to be prescribed for this client?
a. Calcium acetate
b. Doxycyline
c. Magnesium sulfate
d. Lisinopril

Answer 57

A. calcium acetate

The client with CKD often has a high phosphorus level which tends to lower the calcium level in an inverse relationship, and causes osteodystrophy. To prevent this bone disease, the client needs to take a drug that can bind with phosphorus for elimination via the GI tract. When phosphorus is lowered to within normal limits, normal calcium levels may be restored.

Question 58

The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for postrenal acute kidney injury (AKI)? (Select all that apply.)
a. Client with prostate cancer
b. Client with blood clots in the urinary tract
c. Client with ureterolithiasis
d. Client with severe burns
e. Client with lupus

Answer 58

ANS: A, B, C

Urine flow obstruction, such as prostate cancer, blood clots in the urinary tract, and kidney stones (ureterolithiasis), causes postrenal AKI. Severe burns would be a prerenal cause. Lupus would be an intrarenal cause for AKI.

Question 59

A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse would prompt immediate action to prevent acute kidney injury? (Select all that apply.)
a. Urine output of 100 mL in 4 hours
b. Urine output of 500 mL in 12 hours
c. Large amount of sediment in the urine
d. Amber, odorless urine
e. Blood pressure of 90/60 mm Hg

Answer 59

ANS: A, C, E
The low urine output, sediment, and blood pressure would be reported to the primary health care provider. Postoperatively, the nurse would measure intake and output, check the characteristics of the urine, and report sediment, hematuria, and urine output of less than 0.5 mL/kg/hr for 3 to 4 hours. A urine output of 100 mL is low, but a urine output of 500 mL in 12 hours would be within normal limits. Perfusion to the kidneys is compromised with low blood pressure. The amber odorless urine is normal.

Question 60

A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the client’s spouse about the renal-specific formulation for the enteral solution compared to standard formulas. What components would be discussed in the teaching plan? (Select all that apply.)
a. Lower sodium
b. Higher calcium
c. Lower potassium
d. Higher phosphorus
e. Higher calories

Answer 60

ANS: A, C, E
Many clients with AKI are too ill to meet caloric goals and require tube feedings with renal-specific formulas that are lower in sodium, potassium, and phosphorus, and higher in calories than are standard formulas.

Question 61

The nurse is caring for a client with a new diagnosis of chronic kidney disease. Which priority complications would the nurse anticipate? (Select all that apply.)
a. Dehydration
b. Anemia
c. Hypertension
d. Dysrhythmias
e. Heart failure

Answer 61

ANS: B, C, D, E
The client who has CKD has fluid overload and electrolyte imbalances, especially hyperkalemia, that can cause hypertension, heart failure, and dysrhythmias. Anemia results because erythropoietin production by the kidneys is decreased.

Question 62

A nurse is giving discharge instructions to a client recently diagnosed with chronic kidney disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.)
a. “I can continue to take antacids to relieve heartburn.”
b. “I need to ask for an antibiotic when scheduling a dental appointment.”
c. “I’ll need to check my blood sugar often to prevent hypoglycemia.”
d. “The dose of my pain medication may have to be adjusted.”
e. “I should watch for bleeding when taking my anticoagulants.”

Answer 62

ANS: B, C, D, E
In discharge teaching, the nurse must emphasize that the client needs to have an antibiotic prophylactically before dental procedures to prevent infection. There may be a need for dose reduction in medications if the kidney is not excreting them properly (antacids with magnesium, antibiotics, antidiabetic drugs, insulin, opioids, and anticoagulants).

Question 63

A client is undergoing hemodialysis. The client’s blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions would the nurse perform to maintain blood pressure? (Select all that apply.)
a. Adjust the rate of extracorporeal blood flow.
b. Place the patient in the Trendelenburg position.
c. Stop the hemodialysis treatment.
d. Administer a 250-mL bolus of normal saline.
e. Contact the primary health care provider.

Answer 63

ANS: A, B, D
Hypotension occurs often during hemodialysis treatments as a result of vasodilation from the warmed dialysate. Modest decreases in blood pressure, as is the case with this client, can be maintained with rate adjustment, Trendelenburg positioning, and a fluid bolus. If the blood pressure drops considerably after two boluses and cooling dialysate, the hemodialysis can be stopped and the primary health care provider contacted.

Question 64

A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are correct regarding PD? (Select all that apply.)
a. “You will not need vascular access to perform PD.”
b. “There is less restriction of protein and fluids.”
c. “You will have no risk for infection with PD.”
d. “You have flexible scheduling for the exchanges.”
e. “It takes less time than hemodialysis treatments.”

Answer 64

ANS: A, B, D

PD is based on exchanges of waste, fluid, and electrolytes in the peritoneal cavity. There is no need for vascular access. Protein is lost in the exchange, which allows for more protein and fluid in the diet. There is flexibility in the time for exchanges, but the treatment takes a longer period of time compared to hemodialysis. There still is risk for infection with PD, especially peritonitis.

Question 65

A nurse is caring for a client with an electrical burn. The client has entrance wounds on the hands and exit wounds on the feet. What information is most important to include when planning care?
a. The client may have memory and cognitive issues postburn.
b. Everything between the entry and exit wounds can be damaged.
c. The respiratory system requires close monitoring for signs of swelling.
d. Electrical burns increase the risk of developing future cancers.

Answer 65

B.Everything between the entry and exit wounds can be damaged.

As the electricity enters the body, travels through various tissues, and exits, it damages all the tissue it flows through. There may be severe internal injury that is not yet apparent. The client may have cognitive issues postburn but this is not as important as vigilant monitoring for complications. Respiratory system swelling is associated with thermal burns and smoke inhalation. Exposure to radiation increases cancer risk.

Question 66

A client has been brought to the emergency department after being covered in fertilizer after an explosion and fire at a warehouse. What action by the nurse is best?
a. Assess the client’s airway.
b. Irrigate the client’s skin.
c. Brush any visible dust off the skin.
d. Call poison control for guidance

Answer 66

A. Assess the client’s airway

With any burn client, assessing and maintaining the airway is paramount. Airway tissues can swell quickly, cutting off the airway. The fertilizer would then be brushed off before irrigation. Poison control may or may not need to be called.

Question 67

The nurse learns that which age-related changes increase the potential for complications of burns? (Select all that apply.)
a. Thinner skin
b. Slower healing time
c. Decreased mobility
d. Hyperresponsive immune response
e. Increased risk of unnoticed sepsis
f. Pre-existing conditions

Answer 67

ANS: A,B,C,E,F

Age-related differences that can increase the risk of burns and complications of burns include thinner skin, slower healing, decreased mobility, increased risk of infection that goes unnoticed, and pre-existing conditions that can complicate recovery. The older adult has decreased inflammatory and immune responses.

Question 68

The nurse in the emergency department would arrange to transfer which burned clients to a burn center? (Select all that apply.)
a. 15% partial-thickness burn
b. Lightening injury
c. 7% partial-thickness burn
d. History of pulmonary edema
e. Healthy 67 year old
f. 4% partial-thickness burn to perineum

Answer 68

ANS: A,B,D,E,F

Clients with major burns are transferred to a burn center for specialized care. These include any partial-thickness burn over 10% TBSA; any lightening injury; a burn injury in a client with a history of pre-existing conditions that could complicate care or prolong recovery; adults over the age of 60; and burns to the face, hands, feet, genitalia, perineum, or major joints. The client with a 7% partial-thickness burn could be cared for in a hospital or a burn center.